Treatment Consultation Please enable JavaScript in your browser to complete this form.1Personal Details2Medical History3Current skin care4ConsentYour personal detailsNameDate of BirthGenderFemaleMaleAddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodePhoneEmailNextMedical HistoryPlease let me know if you suffer from any of the followingAllergiesYes NoArthritisYes NoHeadaches/migrainesYes NoEpilepsyYes NoInsomniaYes NoBlood pressureYes NoThyroid problemsYes NoHepatitisYes NoIBSYes NoNervous disorderYes NoOsteoporosisYes NoSinusitisYes NoDiabetesYes NoAsthmaYes NoCardiac problemsYes NoKidney/liver ailmentsYes NoHormonal problemsYes NoSkin diseaseYes NoClaustrophobiaYes NoBack problemsYes NoRecent injuryYes NoRecent illnessYes NoRecent surgery (last 12 months)Yes NoAbout youPhysical stress levelsHighMediumLowEmotional stress levelsHighMediumLowEnergy levelsHighMediumLowPreviousNextFacial treatmentsProduct range(s) currently used?What is your current skincare routine?What are your concerns?What would you like to achieve from your facial today?Do you mind product being used in your hair?Yes NoNextConsentI consent to this data being stored in the Skinologist client database and used only by Skinologist for reference purposes *Yes, I consentYour data will not be shared with third partiesPatient signaturePlease type full nameDateUpload a photo of your skin (optional) Click or drag a file to this area to upload. Anything else you would like to add?NameSubmit